Health Care Utilization

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Blacks hospitalized for congestive heart failure more often
than whites

Black men younger than 60 years of age are twice as likely as
similarly aged white men to be hospitalized for congestive heart
failure (CHF). Black women in this age group are nearly three
times as likely as similarly aged white women to be hospitalized
for CHF. Older blacks are hospitalized 1.5 times more often than
whites for this condition, according to a recent study supported
by the Agency for Health Care Policy and Research (HS07373). The
higher prevalence of hypertension and diabetes among blacks,
conditions that can contribute to CHF, explains most of the
racial differences in CHF hospitalization.

After adjusting for these conditions and risk factors, such as
smoking and high cholesterol, race was no longer a factor in CHF
hospitalizations of men and older women. However, after this
adjustment, black women younger than 60 years still were 1.5
times more likely to be hospitalized for CHF than their white
counterparts. Additional burdens, such as responsibility for
child care or the effects of poverty, may impair the ability of
younger black women to receive care and attend to their medical
needs, suggests Eugene Washington, M.D., M.Sc., of the Medical
Effectiveness Research Center for Diverse Populations based at
the University of California School of Medicine, San
Francisco.

The investigators studied the first hospitalization for CHF of
64,877 enrollees in a large health maintenance organization.
These patients had been free of CHF at a health checkup at or
after the age of 40 years. However, these results may not apply
to uninsured or indigent populations, cautions Dr. Washington.

FDA guidelines reduce unnecessary dental x-rays

Currently, the treatment plan of most patients seeking general
dental care is developed after a clinical examination and a
full-mouth set of radiographs. In 1988 the U.S. Food and Drug
Administration (FDA) issued guidelines to assist dentists in
selecting a limited set of x-rays for the examination. This
change in practice was intended to reduce patient exposure to
radiation without compromising patient care.

Even though the rationale for the guidelines was formally
endorsed by dental professional groups, there is evidence that
they are not being used and that use of full-mouth sets remains
common. General dentists have been concerned about the risk of
missed disease and resulting malpractice claims based upon a
failure to diagnose disease.

A recently completed study, supported by the Agency for Health
Care Policy and Research (HS06670), showed that dentists
following the FDA guidelines reduced the number of periapical
radiographs (showing tooth crown to root tip) by 43 percent.
Kathryn A. Atchison, D.D.S., M.P.H., Stuart C. White, D.D.S.,
Ph.D., and colleagues at the University of California, Los
Angeles, Schools of Dentistry and Public Health, evaluated use of
the guidelines for assessment of 490 new adult dental
patients.

The researchers confirmed that there was a small increased risk
of not detecting an abnormal condition, compared with use of a
full-mouth examination. However, the number of missed
radiographic findings was very low (approximately 4 percent),
considering the level of variability in diagnosis reported in the
literature. Most missed findings would have had no effect on the
patient's treatment.

The researchers noted that demonstration of missed conditions
does not necessarily indicate flaws in the guidelines, since
allowances must be made for the potential harm of radiation
exposure, the costs associated with the additional radiographs,
and possible unnecessary care resulting from false positive
diagnoses made on the basis of too many radiographs. They
concluded that the FDA guidelines are sufficiently reliable and
offered suggestions for their implementation by dentists.

See "Assessing the FDA guidelines for ordering dental
radiographs," by Drs. Atchison and White, Virginia F. Flack,
Ph.D., and Edmond R. Hewlett, D.D.S., in the Journal of the
American Dental Association 126 (10), pp. 1372-1383, 1995.

Editor's Note: For a more complete discussion of the FDA
guidelines and radiographic assessment of the periodontium, see
"Efficacy of the FDA selection criteria for radiographic
assessment of the periodontium," by the same authors in the
Journal of Dental Research 74(7), pp. 1424-1432, 1995.